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1 <br /> r . SERVICE REQUEST • <br /> Type o B iness or Prop FACILITY ID# QQ(� 757 SERVICE REQUEST# <br /> f Ori z <br /> OWNER I JERATOR BILLING PARTY 0 <br /> FACILITY NAME <br /> SITE ADDRESS, <br /> -L/[ Street Number etlon O Steel ; Type swiss <br /> Mailing Address (If Different from Site Address) <br /> CITY TATE ZI — syjn <br /> PHONE#1 ,[ AP N# LA ND USE APPLICATION# j <br /> ( qr <br /> V av' <br /> PHONE ^ _ �E'?•�� BOS DISTRICT LOCATION CODE <br /> O( C� <br /> CISINTRACTORI SERVICE REQUESTOR <br /> REQUESTOR O BILLING PARTY <br /> BUSINESS NAME r P E# ET. <br /> / —((3�1 <br /> MAILING ADDR ` �, F #59 / /6/— / 2X2 <br /> CITY STATE /7 <br /> BILLING KNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepsMi application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. Q <br /> APPLICANT SIGNATURE: DATE <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPucANrisnotffle SUxo Pm pmfafaudrodzation to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ft <br /> COMMENTS: PA ENT <br /> It <br /> P117CE ED RECEIVED <br /> FEB - 4W FEB 04 2000 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> ENVIROr�MENTAL HEALTH DIVSIOt. PERMIT I SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED SY: ^ EMPLOYEE#: DATE: <br /> MS <br /> ASSIGNED TO: r EMPLOYEE#: DQ®g DATE: Z <br /> Date Service Completed (if alrea c pleteft SERVICECQDE: PIE 3, 6 (p <br /> Fee Amount: a3 Amount Paid a 3 Payment Date <br /> Payment Type ✓ Invoice# Check# Received By: <br />